Analysis Local Knowledge of Marine Pilots Compulsory pilotage areas are established to enhance operational safety and to protect the environment from marine accidents. Pilots provide knowledge of local navigation conditions prevailing in the area. The pilot is responsible to the master solely for the safe navigation of the vessel. The master retains overall responsibility for the safety of the vessel but relies on the pilot's local knowledge and ability to handle the vessel in a safe and efficient manner. As the master has to rely on the pilot's in-depth local knowledge, it is essential that pilots keep abreast of new developments in the waterways they are required to navigate. Furthermore, they need to obtain all pertinent navigational information for the intended passage prior to boarding the vessel, especially when they are required to pilot vessels to ports that are not frequented. Some personnel engaged in pilotage activity, be they ship masters or pilots, were aware of the presence of the buoys and that the approach was to pass in between the yellow buoys that marked the dredged area. The bridge team on board the EmeraldStar sought information about the approach to the dock; the pilot was reportedly aware that the yellow buoys marked the dredged channel and that the vessel must transit between them. Voyage Planning A well-planned voyage and continuous monitoring and updating is crucial to ensure safety of navigation and protection of the environment. TC's Recommended Code of Nautical Procedures and Practices (TP1018), the basic principles of which shall be taken into account on all vessels, states that the intended voyage shall be planned in advance taking into consideration all pertinent information and any course laid down shall be checked before the voyage commences.7 International Maritime Organization (IMO) requirements concerning voyage planning also state that the planned route shall be clearly displayed on appropriate charts and shall be continuously available....8 IMO Guidelines for Voyage Planning provide further details on the development of a voyage plan.9 A voyage plan was developed; however, the plan did not identify all pertinent navigational information to safely navigate the approach to the PML dock. Although U.S. NOAA chart14884 showed depths for approaching the PML dock were sufficient for the vessel, depths in the vicinity of the dock were indicated to be insufficient. The sounding survey was therefore used only to verify the available depth of water at the dock. Information contained in the sounding survey was not readily comparable with that on the navigation chart. This information was not transferred to the navigation chart for ease of reference, nor was the chart information transferred to the field sheet to better assist the bridge team in navigating the approach to the dock. The incorporation of this information at the planning stage would have provided the bridge team with an opportunity to carefully consider all pertinent information essential for the safe navigation of the vessel and provided them with the tools to closely monitor the vessel's progress in the narrow approach towards the dock. Furthermore, the sounding survey indicated only one yellow buoy - the position of the easternmost yellow buoy was off the limits of the survey. The buoy that was indicated on the survey was labelled Yellow East but was in fact the westernmost yellow buoy, indicating the southwestern edge of the dredged approach to the PML dock. This had the potential to generate confusion. Given the scale of the U.S. chart in use and the approach to the dock, information contained on the sounding survey was critical to safely navigate the vessel. Consequently, the incorporation and use of this safety critical information during the planning stage would have provided the bridge team with an opportunity to better plan and execute the passage plan. It is noted that mariners are cautioned not to rely solely on buoys for navigation.10 However, given the scale of the chart and the nature of approach to the dock, reference to the buoy with a measure of caution would assist the mariner in better negotiating this approach. Decision Making On passing Mission Point, the master and the pilot saw two buoys at the approach to the PML dock, although only one buoy was marked on the sounding sheet. Given that the operational environment may be subject to change, and consistent with good navigational practices, the master and the pilot reviewed the vessel's approach at this stage. Yellow buoys are used to indicate caution, but on this occasion, were used to mark the dredged channel. Following discussions between the pilot and the master, it was mutually agreed that the master would take over the conduct of the vessel for berthing operations. In determining how best to approach the dock, the master considered the following: that cautionary buoys mark an area where mariners are, amongst other things, warned of areas where no safe through passage exists; that the buoys may have been those left over from the dredging the previous year; that a course steered between the buoys would lead to a difficult, steep approach to the dock; that by steering close to the easterly buoy, the master would be able to take an easy, normal approach to the dock; and that as long as he stayed close to the easterly buoy, he would have sufficient depth for the vessel. The master decided that the most appropriate course would be to avoid the area between the caution buoys by passing as close to the easterly buoy as practicable. In doing so, the master manoeuvred the vessel into closer proximity to shallow water without fully recognizing the dangers associated with the vessel's arrival draughts. Effectiveness of Bridge Resource Management Navigation with a pilot on board creates a situation where the pilot is teamed with an existing crew to carry out a coordinated job. Generally, the pilot has the local navigational knowledge to analyze local cues more readily and take rapid action as necessary and the ship's crew has a greater understanding of the ship's handling characteristics. Because pilots, masters and officers of vessels have different areas of experience and training, it is essential that the skills of each be combined in the working relationship of a bridge team. Consequently, it is essential that pilots play an effective role as a bridge team member. In this instance, the master elected to berth the vessel. However, he was aided in his manoeuvre by the navigational information, assistance and guidance provided by the pilot. The master had received information from the master of the Algonova, berthed at the dock, that it was his practice to pass in between the buoys; however, proper weight was not given to this information in the final decision-making process. Consequently, an opportunity to seek clarification from PML with respect to the purpose of the buoys and the single buoy position as plotted on the sounding sheet was lost. This resulted in less than complete information being available to the bridge team. Although the pilot on board the EmeraldStar was reportedly aware that the yellow buoys marked the dredged channel and that the vessel should transit between them, contrary to Bridge Resource Management principles and objectives, the pilot did not effectively intervene to dissuade the master from proceeding outside the area marked by the buoys. Availability of Sounding Survey Information Upon completion of the dredging in2002 and placement of the yellow buoys near the PML dock, vessels were provided copies of the sounding survey in advance of their calling at the dock by either the vessel owners or charterers. The sounding survey was also provided to the Canadian Hydrographic Service, who forwarded it to the NOAA National Ocean Survey (NOS) for their consideration for use in their chart of the area and/or Notice to Mariners. As a general rule, NOS will only prepare a Notice to Mariners for soundings outside of a channel if the depths are 10percent shallower than existing data. As there was no feature identified in the sounding survey considered to be a danger to navigation, no Notice to Mariners was prepared. Sounding surveys in the vicinity of other private port facilities in the port of Sault Ste. Marie were provided to local pilotage authorities when they became available or upon request. There is no documentation to indicate that the local pilotage authorities were provided with copies of the sounding surveys for the PML dock. On the other hand, the pilotage authority and the pilots ought to have been aware that dredging operations in the vicinity of the PML dock, which had been broadcast in the NOTSHIP, had been completed and that a copy of the sounding sheet was essential for pilots to safely navigate. However, this information was not requested. Use and Assessment of Private Marine Aids In addition to the use of marine aids to navigation operated by a federal or provincial government or agency, other aids to navigation may be placed by private individuals, organizations, companies or other groups for their own use. Known as private aids to navigation, use of these aids have increased over time. When the federal government divests itself of a port facility, it also divests responsibility for sounding, dredging and maintenance of the berths and channels leading to it. Owners and operators of divested port facilities are then required to make more use of private aids to ensure the safety of navigation of vessels calling at their facilities. Owners of private aids are responsible to ensure that their aids meet all of the requirements of the Private Buoy Regulations11 and the Boating Restriction Regulations. CCG may conduct a quality assurance check of a private aid to determine its appropriateness when CCG is aware of the presence of the aid. In addition, CCG offers a service to provide advice on the placement of aids. CCG's The Canadian Aids to Navigation System (TP968E) provides a comprehensive view of the aids to navigation system in Canada. CCG has also developed a guide entitled An Owner's Guide to Private Aids to Navigation to assist private owners in understanding the related legislation, requirements and responsibilities involved with the establishment of a private aid to navigation. In this occurrence, no information about the deployment of yellow buoys in the vicinity of the PML dock was provided to CCG or TC before the occurrence. PML did request advice on the design of the aids; however, CCG did not provide advice other than to offer to review the site to determine which proper aids to navigation would be required to mark the channel once the dredging was completed. CCG was notified when dredging operations were completed and it was also provided with a sketch of the placements of the buoys that were in use. The harbour master of the public port was never informed about the placement of the new buoys. Although 10months had expired since the completion of dredging operations, neither the PML nor the CCG initiated further action to review these buoys. The harbour master of the public port of Sault Ste. Marie did not have knowledge about the buoyage system, and because he was not informed of the use of the buoys, he did not note the anomaly. Therefore, he did not initiate any discussion within TC or with other authorities and port users. CCG does undertake activities to stay aware of the latest placement of private aids to navigation. CCG staff identify the use of private aids by reviewing NOTSHIPs after they are issued. However, the process is informal without a supporting procedure or tools to ensure the tracking of information concerning new placements. A proper assessment of the yellow buoy in the vicinity of the PML dock would have provided an opportunity for the placement of proper aids to navigation to better assist vessels in negotiating the approach to the dock. It is noted that, in the U.S., the placement of a private aid to navigation requires pre-approval. Divestiture Process Considerable work is undertaken by TC staff managing the divestitures in analyzing the financial aspects of each divestiture; however, the divestiture process does not include a risk analysis of the safety issues of transferring the port to a private owner. Limited information is provided to the prospective purchaser to advise them of their responsibilities in relation to the safe operation of the port facility. Many purchasers only become aware of the implications of their responsibilities as issues arise after purchase. The majority of public port facilities have been divested. Public Port Overview TC appoints a harbour master to assist regional staff to oversee a public port. Typically, a harbour master of a port is responsible for the administration and safety of port operations, and overseeing the safe movement of vessels using the port. A review of the roles of responsibilities of the harbour master for this public port indicated that he was acting as the eyes and ears of TC, reporting to TC regional staff. To effectively manage the overview of a public port, there needs to be a balance between the level of supervision by regional staff against the level of knowledge and skills of the harbour master. Harbour masters are required to have the necessary knowledge to effectively carry out their responsibilities, such as the granting of clearance for vessels and the reporting of a breach of practices and procedures. Initial training provided by TC, Ontario Region, is only to ensure that harbour masters know who to contact in TC and how to collect and record harbour dues. The harbour master assigned to this public port did not possess the knowledge or experience, nor did TC provide training to acquire the necessary knowledge or skills for carrying out all of his assigned duties/responsibilities. The training was limited to the requirements of the Canada Labour Code.12 Review and Approval of Dredging in Public Ports For activities where a number of departments/agencies may need to be consulted, there is not always a means of ensuring that the applicant is aware of the necessity to involve all relevant departments/agencies. In the case of dredging operations in a public harbour, TC, the DFO, and the local conservation authority may all need to be involved. In this occurrence, although the DFO and the Ontario Ministry of the Environment were aware of PML's application for dredging to the Sault Ste. Marie Region Conservation Authority, they were unaware that permission to dredge should have been granted by TC. To help facilitate the review and approval process for commercial dredging proposals in Ontario, DFO developed a guidance document.13 The guidance document provides information to proponents of dredging activities as to which department/agency (i.e. DFO, Parks Canada, Ontario Ministries of Natural Resources and Environment, or local conservation authorities) should be contacted for review and approval. There is no mention of TC's residual responsibilities concerning dredging at divested port facilities within a public port. Use of a coordinated approach for approvals ensures that, when one authority is made aware of a proposed activity, all the necessary authorities are informed. Such an approach provides a framework around which informed decisions, essential to the safety of navigation, safe operation of the port and public safety, can be made. However, in the events leading up to this occurrence, this was not the case. The absence of a coordinated approach for the review and approvals of dredging for private port facilities in public ports increases the potential that the risks associated with such activities may not be fully assessed. Reporting an Accident Following the grounding of a vessel, it is incumbent upon the owner to take timely and appropriate action to respond to the situation and initiate remedial action. Furthermore, the activation of any emergency response to supplement that taken on board the vessel can only occur once the appropriate agencies, authorities and organizations have been informed. In this occurrence, the vessel did not inform its owner, charterer or the authorities until more than two hours after the time of the grounding and only after the USCG inquired about the vessel's intentions. Notwithstanding the vessel in this occurrence was of double-hulled construction and there was no pollution, emergency situations generally tend to be dynamic and their outcomes may not be as anticipated. Delays in reporting emergency situations to those who have expertise for responding to such situations may pre-empt an opportunity to take necessary precautionary measures that might otherwise not have been considered by the crew of the vessel, thereby unnecessarily exacerbating the situation. Corrective action can be taken if occurrence-related information is disseminated to the authorities that are in a position to effect change. Although reports of occurrences are required to be made to the GLPA by those who have the conduct of a vessel at the time of the occurrence, the practice of U.S. Great Lakes pilots is that they do not submit reports to the GLPA nor does GLPA request one. Consequently, an opportunity to identify, correct and learn from non-conformities, and analysis of safety-critical incidents and near misses is lost and the potential safety benefits to the marine community cannot be fully realized. Further, given that there are common elements in the waters shared by the U.S. and Canada, safety benefit can be fully realized by sharing information on occurrences and by identifying safety deficiencies associated with all occurrences. However, there is no such system in place. A voyage plan was developed; however, the plan did not identify all pertinent navigational information, including that contained in the sounding survey, to safely navigate the approach to the Purvis Marine Limited (PML) dock. Yellow buoys are used to indicate caution, but on this occasion, they were used to mark the dredged channel. The dredging of the channel had been completed some months earlier and neither PML nor the Canadian Coast Guard (CCG) took measures to have the buoys replaced with appropriate navigational markers. Although the pilot was reportedly aware that the yellow buoys marked the dredged channel, contrary to Bridge Resource Management principles and objectives, he did not effectively intervene to dissuade the master from proceeding outside the area marked by the buoys. The master manoeuvred the vessel into shallow water without fully recognizing the dangers associated with the vessel's draught.Findings as to Causes and Contributing Factors A voyage plan was developed; however, the plan did not identify all pertinent navigational information, including that contained in the sounding survey, to safely navigate the approach to the Purvis Marine Limited (PML) dock. Yellow buoys are used to indicate caution, but on this occasion, they were used to mark the dredged channel. The dredging of the channel had been completed some months earlier and neither PML nor the Canadian Coast Guard (CCG) took measures to have the buoys replaced with appropriate navigational markers. Although the pilot was reportedly aware that the yellow buoys marked the dredged channel, contrary to Bridge Resource Management principles and objectives, he did not effectively intervene to dissuade the master from proceeding outside the area marked by the buoys. The master manoeuvred the vessel into shallow water without fully recognizing the dangers associated with the vessel's draught. In the absence of a system for exchange/transfer of information between the U.S. and Canadian pilotage authorities on occurrences, and by identifying safety deficiencies associated with all occurrences, safety benefit cannot be fully realized in the waters shared by the U.S. and Canada.Findings as to Risk In the absence of a system for exchange/transfer of information between the U.S. and Canadian pilotage authorities on occurrences, and by identifying safety deficiencies associated with all occurrences, safety benefit cannot be fully realized in the waters shared by the U.S. and Canada. To effectively manage the overview of a public port, there needs to be a balance between the level of supervision by regional staff against the level of knowledge and skills of the harbour master. The absence of a coordinated approach for the review and approvals of dredging for private port facilities in public ports increases the potential that the risks associated with such activities may not be adequately assessed. A delay in reporting an emergency situation to the competent authorities has the potential to delay corrective action.Other Findings To effectively manage the overview of a public port, there needs to be a balance between the level of supervision by regional staff against the level of knowledge and skills of the harbour master. The absence of a coordinated approach for the review and approvals of dredging for private port facilities in public ports increases the potential that the risks associated with such activities may not be adequately assessed. A delay in reporting an emergency situation to the competent authorities has the potential to delay corrective action. Safety Action Action Taken Private Aids to Navigation in the Vicinity of Purvis Marine Limited Purvis Marine Limited (PML) painted the buoys red and green. Subsequently, at the request of Imperial Oil, they were removed from service on 18July2003. Vessel Owners, Operators and Charterers Rigel Shipping Canada prepared a recommended docking plan for the port of Sault Ste. Marie and PML dock for the guidance of all company masters. A general circular was issued in which the minimum acceptable underkeel clearance is 0.30m. Company masters were reminded of the necessity to ascertain the qualifications, experience and capability of pilots. Algoma Tankers Limited informed their vessels calling at the PML dock to ensure that the minimum arrival underkeel clearance of one foot for double-hulled tankers and two feet for single-hulled tankers be based on a 21-foot chartdatum. Imperial Oil instructed their vessels calling at the PML dock to restrict their draught to that compatible with the available water depths as published in the official hydrographic chart of the area (i.e. U.S. National Oceanic and Atmospheric Administration [NOAA] chart14884) and the prevailing water level. Transport Canada Following the occurrence, Transport Canada (TC) initiated the following measures: The Ontario Regional TC office has been added to the Ontario Conservation Authority list of affected department/agencies for activities taking place in TC public ports. The duties and responsibilities of this particular harbour master have been reviewed and amended to require him to carry out more frequent inspections/tours of the public port. TC will request that all regional offices review the frequency of the required inspections/tours assigned to individual harbour masters/wharfingers as part of their duties and responsibilities. TC Ontario Region held its annual harbour master/wharfinger seminar on 20and 21March2004. The agenda for the seminar included: emergency plans and planned exercises, and discussion of the lessons to be learned from this occurrence. Under reorganization, the return of the Navigable Waters Protection Program to TC is expected to foster a closer working relationship. Safety Concern Private Aids to Navigation Systems for Commercial Shipping It is noted that the onus for ensuring that private aids to navigation comply with all applicable regulations and standards rests with the owner of the aid to navigation; however, the regulations and standards do not provide information regarding the determining of proper aids and their placement for a waterway. Owners are asked to contact the Canadian Coast Guard (CCG) for advice on the design of a navigation system for a waterway. In this occurrence, neither the CCG nor the owner of the private aids to navigation took follow-up action to have the approach to the PML dock inspected to determine the proper aids to navigation to mark the channel. CCG staff identify the use of private aids by reviewing Notices to Shipping; however, the process is informal without supporting procedures or tools to ensure the tracking of information concerning new placements. CCG may also be made aware of the presence of private aids by their own vessels, when they come across them. As the level of federal marine-related infrastructures and services continues to be rationalized for cost effectiveness and efficiencies, more owners and operators are expected to make use of private aids to navigation to ensure the safe navigation for commercial vessels calling at their ports and facilities. Commercial vessels, such as petroleum tankers, pose a substantial risk to the environment when involved in an accident. As a consequence, the Board is concerned that, without adequate procedures in place to ensure the appropriateness of private aids to navigation systems, commercial vessels will continue to be placed at risk. The Board will continue to monitor the situation.